Elizabeth Zeidler Schreiter, Psy.D., PsychologistMeghan Fondow, Ph.D., PsychologistJantina Vonk, MD, PsychiatristChantelle Thomas, Ph.D., PsychologistAccess Community Health Centers- Madison, WI

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session: E5aOctober 29, 20111:30 PM to 2:15 PM

I/We currently have or have had the following relevant financial relationships (in any amount)

during the past 12 months: Fairleigh Dickinson University Certificate Program in

Integrated Primary Care-Dr. Zeidler Schreiter is an expert presenter for this program.

Primary care is frequently referred to as the “de facto” mental health system in the United States (Cummings et. al., 2001)

Medical clinicians are facing a burden of an ever increasing number of patients presenting with major mental illness and/or high risk lifestyle behaviors, as seen within our Federally Qualified Health Center (FQHC).

Research has shown that in the current treatment model (clinics that do not have integrated care and refer patients elsewhere for mental health treatment) less than one-third of referrals are actually completed (Miranda et. al., 1994).

Primary care physicians prescribe approximately 60% to 70% of the psychotropic medications prescribed in the United States (Pirl et. al., 2001).

Given the above issues increased access to consulting psychiatry is needed to provide optimal management of increasingly severe patients within the primary care setting.

Upon completion of this presentation, participants will be able to:

Identify components of a consulting psychiatry approach within primary care and potential impact on PCP practice habits.

Describe how behavioral health consultation and psychiatry can work together in a primary care setting to enhance outcomes.

Have knowledge to assist with implementing consulting psychiatry within their practice setting.

List core competencies of a consulting psychiatrist who would fit well within primary care.

Have knowledge how to utilize BHC to assist with coordination and access to psychiatry consultation within clinic.

FQHC, Health Care Home 3 clinic locations in Madison, WI Medical, Dental, Behavioral Health

Services Over 23,000 patients seen in 2010 Over 105,000 visits for 2010

Primary Care Behavioral Health model (Robinson & Reiter, 2007)

Fully integrated, fully embedded program

Mix of scheduled follow ups and warm hand-offs

BHC serves as conduit for referrals to consulting psychiatry

Depressive and anxiety disorders in medical patients have been associated with increased utilization of medical services leading to increased cost , significant functional impairment, and sub-optimal adherence rates in patients with chronic medical issues (Simon et. al., 1995).

Many of these patients can be successfully managed within a primary care environment as evidenced in recent study by Serrano & Monden (2011) with assistance from BHC and access to consulting psychiatry.

BHC saw about 27% of medical patients in 2010 at 2 sites, about 12% at 3rd site

Demographics: 47% Caucasian 27% African American 24% Hispanic

19% Spanish speaking for BHC

Not just mental health issues. Preventive Health and Behavioral Health needs also very salient

Depression and Anxiety commonly seen, but also other mental and behavioral health issues Bipolar disorder, psychotic spectrum

disorders, AODA, adjustment, ADHD, smoking cessation, sleep problems, weight management

Explanation of consulting psychiatry service Population based care

Modalities Chart review Face to face Verbal recommendations Education

Golden Rule: Primary Care Physician retains prescribing authority

Research has discussed several options to increase collaboration between psychiatry and primary care. Possible options:1. Psychiatrist working as specialists who can be consulted as needed2. Increasing referrals from practitioners to psychiatrists3. Integrated team model, in which the psychiatrist and other mental

health providers work alongside their primary care colleagues in primary care environment (Cowley et. al., 2000).

Integrated consulting psychiatry is highly desirable given volume of patients that receive their psychiatric care within the primary care system and issues with poor follow-up when referred outside of the system.

Allows residents exposure to community psychiatry Able to see wide variety of patients Working in collaboration with primary care providers

and BHC Prepares resident to work within a medical home Learn to recognize and diagnose psychiatric and/or

behavioral conditions common in primary care settings

Main requests focused on diagnostic clarification, medication recommendations, management of psychiatric issues co-morbid with physical health issues, and guidance regarding needed lab monitoring.

Primary diagnoses seen include: Mood disorders, schizophrenia/psychotic disorders, PTSD/Anxiety disorders.

Many patients also had co-morbid substance abuse issues.

Patient numbers as seen face-to-face by Consulting Psychiatry: 2010: 210 patients 2009: 170 patients 2008: 107 patients 2007: 34 patients

Over 350 verbal or written consultations in 2010

Resident started 3rd quarter 2010

Consulting psychiatry started at ACHC in 2007. Administrative backing. Needs assessment of clinic is warranted to determine

best fit and time needed. Population care focus thus emphasis on verbal and

written consultations in addition to face-to-face encounters.

Psychoeducation for medical providers Space for consultant to work (e.g. exam room) Finding a psychiatrist ready, willing, and able to thrive in

this environment. Utilization of Behavioral health consultant to assist with

triaging need and appropriate allocation of resources.

Flexible Confident Able to function as part of a team Understanding of context-working

within an FQHC and limited patient resources

Population based care focus

Dr. Jantina Vonk, MD Consulting psychiatrist at Access

Community Health Centers Started in 2007 Training background and experiences

Comparing and contrasting roles within community mental health center and primary care environment (within an FQHC).

Review of structure of initial consultation and brief follow-up consultations as needed.

Use of electronic medical record. Educating providers on utilization of

medication algorithms for mental health issues.

Questions?

Cowley, D.S., Katon, W., & Veith, R.C. (2000). Training psychiatry residents as consultants in primary care settings. Academic Psychiatry, 24:3, 124-130.

Cummings, N.A., O’Donohue, W., Hays, S.C., & Follette, V. (2001). Integrated behavioral healthcare: Positioning mental health practice with medical/surgical practice. San Diego: Academic Press.

Katon W, Von Korff M, Lin E, et al: Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995; 273:1026–1031

Miranda, J., Hohnmann A.A., Attikisso, C.A. (1994). Epidemiology of Mental Health Disorders in Primary Care. San Francisco, CA: Jossey-Bass.

Pirl, W.F., Beck, B.J., Safren, S. A., Kim, H (2001). A descriptive study of psychiatric consultations in a community primary care center. Primary Care Companion Journal of Clinical Psychiatry, 3, 190-194.

Robinson, P.J. and Reiter, J.T. (2007). Behavioral Consultation and Primary Care (pp 1-16). N.Y.: Springer Science.

Serrano, N and Monden, K. (2011). The effect of behavioral health consultation on the care of depression by primary care clinicians. Wisconsin Medical Journal, 110:3, 113-118.

Simon GE, Ormel J, Von Korff M, et al: Health care costs associated with depressive and anxiety disorders in

primary care. American Journal of Psychiatry 1995; 152:352–357.

Slay, J.D., & McCleod, C. (1997). Evolving an integration model: The Healthcare Partners experience.  In N.A. Cummings, J.L. Cummings, and J. Johnson (Eds.) Behavioral health in primary care: A guide for clinical integration (pp 121-144).  New York: International Universities Press.

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!